What is the recommended management for sepsis diagnosis?

Recommended Management for Sepsis Diagnosis

Sepsis diagnosis requires immediate recognition and treatment, with administration of IV antimicrobials within one hour of recognition as the cornerstone of management to reduce mortality. 1, 2, 3

Initial Assessment and Recognition

• Implement routine screening of potentially infected seriously ill patients to increase early identification of sepsis 2, 3
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 1, 2
• Measure serum lactate levels as a marker of tissue hypoperfusion and guide resuscitation 1, 4
• Perform imaging studies promptly to confirm potential sources of infection 2, 3

Immediate Resuscitation

• Administer intravenous antimicrobials within one hour of recognizing sepsis or septic shock 1, 2, 5
• Provide initial fluid resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1, 2
• Reassess hemodynamic status frequently after initial fluid resuscitation to guide additional fluid therapy 1
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 4
• Consider guiding resuscitation to normalize lactate in patients with elevated lactate levels 1, 2

Antimicrobial Therapy

• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (bacterial, fungal, or viral) 1, 3, 5
• Consider the local patterns of antimicrobial resistance when selecting empiric therapy 1, 6
• For septic shock, use combination therapy with at least two antibiotics of different antimicrobial classes aimed at the most likely bacterial pathogens 1, 3
• Reassess antimicrobial regimen daily for potential de-escalation once culture results are available 1, 2, 5
• Limit empiric combination therapy to no more than 3-5 days 2, 7
• Typical duration of antimicrobial therapy is 7-10 days, with longer courses for slow clinical response 2, 6

Source Control

• Implement source control interventions (drainage, debridement) as soon as possible after diagnosis 2, 4
• Remove any foreign body or device that may potentially be the source of infection 4

Hemodynamic Support

• Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 2, 3
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 2
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose 2
• Consider dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate volume and MAP 2
• Consider intravenous hydrocortisone (up to 300 mg/day) in patients requiring escalating dosages of vasopressors 2, 4

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 2, 4
• Place patients in a semi-recumbent position (head of bed elevated 30-45°) 2, 3
• For patients with sepsis-induced ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight) 2, 4
• Consider higher PEEP in moderate to severe ARDS and prone positioning for patients with PaO2/FiO2 ratio <150 2

Metabolic Management

• Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 2, 3
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours 2, 3

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour significantly increases mortality - each hour of delay in antibiotic administration is associated with an average 7.6% decrease in survival 2, 8
• Failure to identify and control the source of infection promptly can lead to persistent sepsis 2, 9
• Overlooking the need for frequent reassessment and de-escalation of antimicrobial therapy can contribute to antimicrobial resistance 2, 5
• Previous antimicrobial therapy is one of the most important risk factors for resistant pathogens, which must be considered when selecting empiric therapy 1, 9